Removal of Restrictions on Pathology Request Forms Discussion Paper

This paper sets out issues relating to a 2009-10 Budget measure that seeks to increase patient choice by removing restrictions on pathology requesting procedures. It is intended to form a basis for discussion that seeks to identify and resolve any implementation issues.

Page last updated: 27 November 2012

Policy Implementation Section
Diagnostic Services Branch
Department of Health and Ageing
MDP 107
GPO Box 9848
CANBERRA ACT 2601

Not later than Monday 22 February 2010.
Removal of Restrictions on Pathology Request Forms Discussion Paper (PDF 61 KB) printable version

Introduction

In the 2009-10 Budget, the government announced changes to the rules relating to pathology request forms. These changes would remove restrictions to improve patient choice and increase competition on price and convenience for patients among pathology providers.

Currently, the Health Insurance Act 1973 requires that, in most cases, in order for a Medicare benefit to be payable for a pathology service, a request for the service must be made to that particular pathology provider (either the pathologist themselves or the proprietor of the laboratory). This means that a patient is effectively required to attend the pathology provider named on the request form in order to be entitled to a Medicare benefit for the pathology service rendered.

From 1 July 2010 this restriction will be removed, so that, while there will still be a legislative requirement for a request for a pathology service to be made, there will no longer be a requirement that the request be made to a particular pathology provider. This legislative change will allow patients to take a pathology request to an approved pathology practitioner or authority of their choice.

This measure removes the anomaly between the requesting requirements for pathology and diagnostic imaging under the current Medicare arrangements, whereby patients are able to take a request for diagnostic imaging to a diagnostic imaging provider of their choice, but are restricted to the approved pathology practitioner or approved pathology authority designated on the request form.

In addition, a change to relevant regulations is planned to require that requests for pathology services include a clear and understandable statement, which is obviously positioned, making patients aware that requests can be taken to any approved pathology practitioner or approved pathology authority. Approved pathology authorities will have twelve months from 1 July 2010 to introduce the new request forms. This transition period has been allowed to minimise cost and disruption.

A similar change is planned to relevant regulations regarding diagnostic imaging, such that diagnostic imaging request forms will also have to include a statement informing patients of their right to take the form to the provider of their choice.

Consultation

The decision to amend the current requirements concerning the requesting of pathology services under the Medicare arrangements was informed by a review of pathology services and funding, conducted by an Interdepartmental Committee comprising the Department of Finance and Deregulation, the Department of the Prime Minister and Cabinet, the Treasury and the Department of Health and Ageing. This review considered over 30 submissions by peak pathology professional representative colleges and industry bodies.

The Department of Health and Ageing would like to ensure that the implementation and management of this measure is sensitive to the interests of patients, pathology providers and treating doctors who request pathology. Therefore this discussion paper sets out issues that have been identified and invites input and comment from these stakeholders.

Operation of the New Arrangements

The new arrangements for pathology request forms will commence on 1 July 2010, with a transition period of twelve months before producers of request forms are required to include on their forms a statement making patients aware that requests can be taken to any approved pathology practitioner or approved pathology authority.

To implement these measures, processes are currently in place to introduce a bill into parliament to make a number of changes to the Health Insurance Act 1973 (the Act).

Section 16A(3) is the key subsection of the Act that currently indicates that Medicare benefits are not payable for a pathology service unless a request for the service is made to the pathology practitioner. This wording will be removed. Similarly, various consequential amendments to wording in sections 16A and 23DK and subsection 3(1) will be made for consistency.

Note that these amendments will preserve the legislative requirement for a request to be made for the service. Where relevant, wording has been changed from “a request made to the practitioner” to “a request received by the practitioner.”

Arrangements are currently being made to introduce the Bill into Parliament. It is anticipated that it may be introduced in the Autumn sittings of parliament, in February/March 2010.

From the HIA changes on 1 July 2010 there will be a twelve month transition period before it will be mandatory for pathology (and diagnostic imaging) request forms to include a statement advising patients that they can take the form to any provider. This will allow time for pathology providers to implement changes to their printing procedures and to use existing stock. The details of how the advice will be worded and presented on the form are yet to be decided and input from stakeholders during this consultation phase is welcome.

Issues

1.Informed patient choice

The Government supports a patient’s right to choose their pathology provider, just as they are entitled to choose their own GP or any other medical practitioner. The timing of the patient’s exercise of choice of pathology provider will be critical. Ideally, the patient will make their choice of preferred provider in discussion with their requesting practitioner and leave the consultation with a request form addressed to the provider of their choice. This is the same process for a patient receiving a referral to any other medical speciality.

Practitioners making pathology requests will still be able - indeed, should be encouraged - to discuss with patients the provider best suited to their needs. As the RACGP Standards for General Practice (3rd Edition) acknowledges:

“The relationship between doctor and patient is a special one, based on trust and communication. While the patient is the ultimate decision maker, it is important for the patient to be well informed in order to make such decisions”.

In order to make an informed choice of provider, patients will need to consider carefully the advice of their treating doctor, as failure to do so may have negative impacts on their care.

While there will be nothing to prevent patients changing their minds or making their final choice after the encounter with the requester, it will be important to ensure that patients understand the potential consequences of not keeping their requesting practitioner informed of their intentions.

These include:
  • Doctors develop familiarity with the reporting style of their preferred provider. A patient taking their request to a different provider may hinder accurate and timely interpretation of results by the treating practitioner.
  • Doctors have a legal obligation to act upon the results of pathology that they request. In cases where they have not received the results they may face difficulty in pursuing them if they don’t know to which provider the patient took the request.
  • Treating doctors and pathologists often have specialised infrastructure and procedures in place to expedite communication between them, which can be valuable in relaying urgent results and increasing efficiency for both parties. These benefits may be lost if patients take the request form to a different provider.
  • Chronic conditions sometimes require regular monitoring with pathology tests. Inconsistencies in the methods, equipment and reporting styles used by different pathology providers may limit the comparability of results and thus inhibit tracking over time.
  • Not all pathology providers perform all tests. Patients may be turned away if a provider does not offer one or more of the tests on the request form.

Issue: What are the most effective strategies for ensuring that patients are informed in choosing their pathology provider, and understand the importance of keeping their requesting practitioner informed of their choices?

2. Factors which might affect patient choice of pathology provider

This measure is being introduced at the same time that other competition focussed changes to the pathology environment are occurring. The removal of restrictions on the number of collection centres a provider can operate has the potential to lead to an increase in available collection centres which will offer patients wider choice.

Users of pathology will range from the casual, infrequent user for non critical tests, to those who have need of regular/frequent testing, including patients with certain conditions, or those taking certain medicines, such as Warfarin where the results will be clinically significant. The factors which are likely to affect a patient’s decision on which provider to use will be similarly varied. Convenience and cost can be expected to figure highly. Frequent users also appreciate the familiarity of a setting in which they feel comfortable, such as access to a phlebotomist who they feel is particularly skilled or sensitive to their patients’ needs. However, even these regular users may be persuaded to change providers if significant changes in billing practices occur. While pathology has historically had a high rate of bulk billing and many patients are unaccustomed to having out of pocket costs, should the billing practices of their regular provider change, it could provide a catalyst to seek another provider.

Issue: What factors currently influence patient choice of provider? What impact will increased choice (through more collection centres) or greater variability in billing practices between providers have on patient preferences?

3. Types of request

Three main types of request have been identified.
  1. The treating doctor writes out or types a request on a pre-printed request form, and hands this to the patient to take to the pathology provider; or
  2. The treating doctor makes a verbal request for the pathology service directly to the pathology provider, then confirms this request in writing within 14 days; or
  3. The treating doctor submits an electronic request directly to the pathology provider and also provides the patient with a paper request to carry. A paper copy is typically required for combined request and assignment of benefit forms.
In the second and third cases described above, the request is sent directly by the treating doctor to the pathologist. These scenarios emphasize the importance of the active involvement of the patient in decision making at the point of request, as in these cases, it will be the only opportunity for the patient to be involved in the choice of provider. However, as previously stated, regardless of the type of request, this is the optimal time for patients to exercise their choice.

4.Types of collection

In 2008/09, almost 55% of Medicare eligible episodes of pathology were initiated through a collection at an approved pathology collection centre. In this scenario, the patient’s choice of provider is self evident by them presenting themselves at a particular provider’s premises.

Pathology providers typically have arrangements with requesters where the provider’s staff will pick up samples from the surgery. In 30% of episodes samples are collected from the requesting doctor’s surgery by a pathology collector, after the patient has left the requesting encounter. This essentially limits the patient’s choice to a provider with which the surgery has such an arrangement. In these situations it must be assumed that having accepted a request form with a particular provider’s details, and left a specimen for collection under the arrangements in place at their requester’s premises, that the patient intended it to be collected by that provider. of provider other than that contracted by the hospital would be quite impractical and could lead to significant inefficiency. By choosing the services of a particular hospital, it could be argued that the patient has made a choice to accept the arrangements in place in that hospital for the provision of pathology services.

It is expected that the changes to the HIA will not affect the current system of referral of specimens from one pathology provider to another.

Issue: Are there collection scenarios where the patient’s intention regarding preferred provider is not clear? How should those scenarios be managed?

5. Professional relationships between requesters and providers

The relationship between requesters and providers of pathology extends beyond the simple cycle of requests and results.

Pathologists are recognised medical specialists in their field and are an important professional resource to requesters. They provide treating practitioners with advice regarding such issues as the appropriate tests to order in a given situation, the significance of particular results, how results should inform ongoing management and future testing, advances in testing technology and details of the rules relating to the eligibility of services for rebates under Medicare.

Established relationships between pathologists and requesters facilitate this valuable exchange of information. These relationships are often built up over years and can incorporate sophisticated communications systems.

Patients exercising their right to choose their pathology provider in an uninformed manner may break down these relationships.

Issue: How can effective professional relationships between requesters and providers of pathology be maintained where patients choose providers other than those preferred by requesters?

6. Form of words for the mandatory statement

As mentioned, the government will make changes to relevant regulations to require pathology request forms to include a clear and understandable statement, which is obviously positioned, making patients aware that requests can be taken to any approved pathology practitioner or approved pathology authority - (this will also apply to requests for diagnostic imaging).

The positioning is important in making the statement stand out from the more technical, medical information on the form. The department invites comment on the following issues:
  • Should the precise wording of the statement be specified in legislation?
  • If yes, what should these words be?
  • What position is most appropriate for the mandatory statement?
  • Are there other particulars that should be mandated (for example, font size, colour etc)?

The following form of words is presented as a starting point for discussion:

The services listed on this form need not be performed by the provider to whom it is addressed to be eligible for Medicare Benefits. If you choose a different provider, it is important that you let your requesting practitioner know.

Issue: What is the most effective way to notify patients of their right to choose their pathology provider and make them aware of their responsibilities? How can this be done with minimal impact on those who produce pathology request forms?

Planned Consultation

This paper is to be circulated to stakeholders in January 2010. Comments are invited by 22 February 2010.

The responses to this paper will form the basis for further discussions. If stakeholders feel that it would be useful to workshop issues by bringing requesters, consumers and providers together, the Department will facilitate a forum, provisionally in March/April 2010. If your organisation is interested in participating in such a forum, please let us know when you respond to this paper.

Comments that identify any issues that have not been raised in this paper or propose potential solutions or opportunities for improvement will be welcomed.

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